Advancing Early Mobility in Critical Care: Evidence Based Strategies for Making it Happen

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1 Advancing Early Mobility in Critical Care: Evidence Based Strategies for Making it Happen Created in Conjunction With Kathleen M. Vollman, MSN, RN, CCNS, FCCM, Page 1 Zinc: US-AC w Zinc: US-AC w 2013 Hill-Rom Services, Inc. ALL RIGHTS RESERVED Disclosures Sage Products Speaker Bureau & Consultant Eloquest Healthcare Speaker Bureau & Consultant Hill-Rom Speaker Bureau & Consultant 1

2 Learning Objectives Create the link of patient advocacy to mobilizing critically ill patients Understand the importance of early patient mobility Recognize the traditional standards of care for patient mobility Identify current practice patterns Understand institutional costs associated with immobility Recognize what evidence supports the use of early mobility Determine how to implement an early mobility protocol Strategies for creating sustainability Notes on Hospitals: 1859 It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm. Florence Nightingale Advocacy = Safety Nightingale F. Notes on Hospitals. Third Edition [Online]. London: Longman; Available from: 2

3 PROTECT THE PATIENT FROM BAD THINGS HAPPENING ON YOUR WATCH Interventional Patient Hygiene Hygiene the science and practice of the establishment and maintenance of health Interventional Patient Hygiene.nursing action plan directly focused on fortifying the patients host defense through proactive use of evidence based hygiene care strategies Incontinence Associated Dermatitis Prevention Program 3

4 INTERVENTIONAL PATIENT HYGIENE(IPH) VAP/HAP Oral Care/ Mobility HAND Patient HYGIENE Catheter Care Skin Care/ Bathing/Mobility CA-UTI CLA-BSI SSI HASI Vollman KM. Intensive Crit Care Nurs, 2013;22(4): Achieving the Use of the Evidence Factors Impacting the ability to Achieve Quality Nursing Outcomes at the Point of Care Value Attitude & Accountability Vollman KM. Intensive Crit Care Nurs, 2013;22(4):

5 Why Is Early Patient Mobility Important? Teach us to live that we may dread, Unnecessary time in bed, Get people up and we may save, Our patients from an early graved RAJ Asher RAJ. The dangers of going to bed. British Medical Journal,1947 December 13 5

6 Potential Complications of Immobility Respiratory: respiratory tract infections, atelectasis, and pulmonary embolism 1 Neurological: depression, anxiety, forgetfulness, and confusion 1 Cardiovascular: postural hypotension, cardiac muscle atrophy, orthostatic intolerance, and deep vein thrombosis 1 Musculoskeletal: osteoporosis, muscle atrophy and weakness, and contractures 3 Hematologic: anemia 1 Renal: calculi 2 Metabolic: glucose intolerance 2 Skin: pressure ulcers 3 Gastrointestinal: constipation and fecal impaction 2 1. Knight J, et al. Nurs Times. 2009;105(21): Knight J, et al. Nurs Times. 2009;105(22): Nigam Y, et al. Nurs Times. 2009;105(23): Effects of Immobility on Respiratory Function 1,2 Decreased movement of secretions Decreased respiratory motion Increased risk of pulmonary embolism Increased dependent edema Increased risk of atelectasis Increased risk of pneumonia Decreased arterial oxygen saturation Respiratory 1. Knight J, et al. Nurs Times. 2009;105(21): Vollman KM. Crit Care Nurse. 2010;30:S3-S5. 6

7 Ventilator-Associated Pneumonia (VAP) Rates In North America In the United States, the Centers for Disease Control (CDC), through the National Healthcare Safety Network, has reported critical care unit VAP rates, per 1,000 ventilator-days, ranging from 0.2 (pediatric cardiothoracic) to 4.4 (burn ICU) 2 On average, ICU patients with VAP had an additional 10.5-day LOS 3 Per case: VAP $40,144. (95% CI, %36,286- $44,220) 4 Respiratory 1. Rosenthal VD, et al. Am J Infect Control. 2012;40(5): Dudeck MA, et al. National Healthcare Safety Network (NHSN) Report, Data Summary for 2012, Device-Associated Module. American Journal of Infection Control. 2013,41: Restrepo MI, et al. Infect Control Hosp Epidemiol. 2010;31(5): Zimlichman E. et al. JAMA Internal Med, 2013;173(22): Accessed 10/2013 at Ventilator-Associated Events-Not a New Definition for VAP The CDC defines ventilator-associated events (VAE) as deterioration in respiratory status after a period of stability, possible infection/inflammation, and laboratory evidence of respiratory infection. Before: VAP was the only VAE that the National Healthcare Safety Network (NHSN) collected data on Now: NHSN has revised its policy to include surveillance of all VAE, including Ventilator-associated conditions (VAC) Infection-related ventilator-associated complications (IVAC) Possible and probable VAP Patient criteria for VAE surveillance Included patients: mechanically-ventilated patients 18 years who have an event on or after calendar day 3 of mechanical ventilation Excluded patients: patients receiving rescue therapies) Device-associated module: ventilator-associated event protocol. NHSN website. VAE_FINAL.pdf. Accessed 2/22/13. 7

8 Effects of Immobility on Cardiovascular Function Fluid shift Occurs when the body goes from upright to supine position 1,2 10% of total blood volume is shifted from lower extremities to the rest of the body; 78% of this is taken up in the thorax 3,4 Decreased blood volume (~15% of plasma volume is lost after 4 weeks of bed rest) 2 Cardiac effects Increased resting heart rate (an increase of ~10 beats/min is observed after 4 weeks of bed rest) 1,2 Cardiac deconditioning 2 Cardiovascular Orthostatic intolerance Increased in bedridden patients due to decreased baroreceptor sensitivity, reduced blood volume, cardiac deconditioning, decreased venous return and stroke volume, and venous distensibility 1,2 1. Winkelman C. AACN Adv Crit Care. 2009;20: Knight J, et al. Nurs Times. 2009;105(21): Harms MP, et al. Exp Physiol. 2003;88: Sjostrand T. Physiol Rev. 1953;33: Effects of Immobility on Integumentary Function The current facility acquired of pressure ulcers is high 7 Setting Facility Acquired Rates Critical Care 3.3% to 53.4% Acute Care 0% to 12% Stage III or IV facility-acquired pressure ulcers are not reimburses & impact value based purchasing 2 The average cost per hospital stay for a patient with a stage III or IV pressure ulcer in the acute care setting is $43, National pressure ulcer Advisory panel, European pressure ulcer Advisory panel and Pan Pacific pressure injury alliance. Clinical practice guideline, Hospital-acquired conditions. Centers for Medicare & Medicaid Services website. Acquired_Conditions.asp. Accessed 1/3/ CMS. Fed Regist. 2008;73: Jankowski IM, Nadzam DM. Jt Comm J Qual Patient Saf. 2011;37: Skin Mobilization of patients is recommended to help prevent pressure ulcers and might coordinate with 2-hour repositioning schedules 4 8

9 Effects of Immobility on Skeletal Muscle Muscle wasting (almost half of the normal muscle strength is lost after 3-5 weeks of bed rest) 1,2 Change in type or density of muscle fibers (muscle protein synthesis decreases by 50% after 2 weeks of bed rest) 2 Muscle wasting occurs early & rapidly during first week of critically illness 3 protein synthesis & protein breakdown Severity increased with multiple organ failure Separate phenotypes of muscle atrophy 1 Primary: bed rest, space flight, limb casting, and denervation Secondary: pathology Musculoskeletal 1. Morris PE. Crit Care Clin. 2007;23: Nigam Y, et al. Nurs Times. 2009;105(23): Puthucheary ZA, et al. JAMA 2013;310(15): Effects of Immobility on Skeletal Muscle (Cont.) During immobilization, the muscle groups involved with transferring and posture lose strength most quickly (shoulders, hip girdle) 1,2,4 After less than a day of immobility, contractures start to develop. After 2-3 weeks of immobility, firmer contractures develop, and after 2-3 months of immobility, surgical correction may be needed 2 Recovering from muscle atrophy caused by immobility takes ~4 weeks. With exercise, disuse weakness is reversed at a rate of ~6%/week 2 Respiratory muscle weakness may occur 4 & is a predictor for prolonged mechanical ventilation and delayed weaning 3 Musculoskeletal 1. Topp R, et al. AACN Clin Issues. 2002;13(2): Nigam Y, et al. Nurs Times. 2009;105(23): De Jonghe B, et al. Crit Care Med. 2007;35(9): Kress JP, Hall JB. N Engl J Med, 2014;370:

10 Effects of Immobility on Neurological Function Delirium 1 Acute, fluctuating change in consciousness and cognition Develops over a brief time period Hyperactive or hypoactive (most common) Associated with higher mortality 3,4 Depression 2 Anxiety 2 Forgetfulness 2 Confusion 2 Neurological Neurological: depression, anxiety, forgetfulness, and confusion 1 1. Vasilevskis EE, et al. Chest. 2010;138: Knight, et al. Nurs Times. 2009;105(21): Ely EW, et al. JAMA 2004;291: Pisani MA, et al. AM J Resp Crit Care Med 2009;180: Brain-ICU Study Multicenter RCT- medical-surgical ICU s 821 patients with ARF or Shock Evaluated in-hospital delirium and cognitive impact 3-12 months post d/c 1 out of 4 cognitive Impairment at 12 months Results 74% of patients developed delirium during hospital stay 3 months: 40% had global cognition scores 1.5 SD below population mean, 26% had scores 2 SD below pop mean 12 months: 34%(older) & 24%(younger) global cognition scores below the mean Pandharipande, PP. et al. N Engl J Med;369:1306:

11 ICU-Acquired Weakness (ICUAW) Definition: Syndrome of generalized limb weakness that develops while the patient is critically ill and for which there is no alternative explanation other than the critical illness itself. 1 A verage Medical Research Council Scale (MRC) score <4 across all muscles tested. Incidence: 25% of patients with prolonged mechanical ventilation will develop ICUAW 1 Est 75,000 pts in US, 1 million worldwide Caused By: 1 Critical illness polyneuropathy and myopathy Combination 1. Fan E, et al. Am J Respir Crit Care Med Dec 15;190(12): Hermans G, et al. Crit Care. 2008;12:238. ICU-Acquired Weakness (ICUAW) Risk factors: Severe Sepsis 1 Duration of mechanical ventilation 1,4 ICU LOS 5 Systemic inflammatory response syndrome 2 Multiple organ failure 2,4 Immobility 2 Use of corticosteroids/neuromuscular blockers 2,3,5 Negative impact: 1,2 Prolong mechanical ventilation Reoccurring respiratory failure & VAP Increased ICU and hospital length of stay Increase mortality 1. Fan E, et al. Am J Respir Crit Care Med Dec 15;190(12): Kress JP et al. N Engl of Med, 2014;370: Hermans G, et al. Crit Care. 2008;12: De Jonghe B, et al. Crit Care Med. 2007;35(9): Needham DM, et al. Am J of Respir and Crit Care Med. 2014;189(10):

12 SCCM and ACCN Practice Guidelines to Address Delirium Society of Critical Care Medicine: Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU 1 Recommend performing early mobilization of adult ICU patients whenever feasible to reduce the incidence and duration of delirium AACN Practice Alert: Delirium Assessment and Management 2 Strategies to decrease delirium risk factors should be used, including early exercise 1. Barr J, et al. Crit Care Med. 2013;41(1): AACN practice alert: delirium assessment and management. Accessed 02/25/13. Effects of Immobility: Conclusion Because the consequences of immobility and bed rest are so severe, mobilizing critically ill patients early appears to have merit. K.M. Vollman Vollman KM. Crit Care Nurse. 2010;30:S3-S5. 12

13 Summary: Importance of Early Patient Mobility Early mobility/rehabilitation is associated with a decrease in the incidence and duration of delirium, as well as numerous adverse effects on the different body systems Benefits of early mobility appear to be associated with reduced time on the ventilator, shorter hospital LOS and lower mortality rates. In addition, early mobility can improve quality of life after the ICU stay Early mobility in critically ill patients is essential to the prevention of complications associated with immobility What Are Some Traditional Standards of Care for Patient Mobility? 13

14 What Are Some Traditional Standards of Care for Patient Mobility? Pressure ulcers and pneumonia Traditional intervention Every 2 hours* Manual turning Head of bed at 30 Out of bed to chair The old standby physician order *Although 80%-90% of surveyed ICU physicians believe that every-2-hour turning should occur, only 57% of them believe that it is currently happening in their ICU Krishnagopalan S. Crit Care Med. 2002;30: How Well Are We Really Doing? Every-2-Hour Turning 14

15 Body Position: Clinical Practice vs Standard Methodology 74 patients/566 total hours of observation 3 tertiary hospitals Change in body position recorded every 15 minutes Average observation time 7.7 hours Online MD survey Results 49.3% of observed time no body position change for > 2 hours 2.7% had an every-2-hour demonstrable body position change 80% to 90% believed every-2-hour position change should occur, but only 57% believed it happened in their ICU Krishnagopalan S. Crit Care Med. 2002;30: Positioning Prevalence Methodology: Prospectively recorded, 2 days, 40 ICUs in the UK Analysis on 393 sets of observations Turn defined as supine position to a right or left side lying Results: Five patients prone at any time, 3.8% (day 1) and 5% (day 2) rotating beds Patients on back 46% of observation Left 28.4% Right 25% Head up 97.4% Average time between turns 4.85 hours (3.3 SD) No significant association between time and age, weight, height, respiratory diagnosis, intubation, sedation score, day of week, nurse/patient ratio, hospital Goldhill DR, et al. Anaesthesia. 2008;63:

16 Potential Barriers to Early Mobilization Patients noted to be turned less Heavier patients 1* Patients receiving vasopressors * Patients receiving a paralytic agent at least once 1 Trauma patients with multiple fractures or high intracranial pressure 1 Perceived patient and environmental barriers to mobilizing ICU patients 2 : Fear of line dislodgement Heavy sedation Patient comfort Human and technological resources Fear of further decreases in oxygenation or hemodynamic parameters 1. Schallom L, et al. Am J Crit Care. 2005;14: Morris PE. Crit Care Clin. 2007;23:1-20. * *not statistically significant EBP Recommendations to Achieve Offloading & Reduce Pressure Turn & reposition (avoid positioning patients on a pressure ulcer) Repositioning should be undertaken to reduce the duration & magnitude of pressure over vulnerable areas Cushioning devices to maintain alignment /30 side-lying & prevent pressure on boney prominences Use lifting device or other aids to reposition & make it easy to achieve the turn Do not leave moving and handling equip underneath the patient Assess whether actual offloading has occurred National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel. And Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed,) Cambridge Media: Perth, Australia; American Nurses Association. Safe patient handling and mobility: Interprofessional national standards. Silver Spring, MD: author;

17 Summary: Traditional Standards of Care Every-2-hour turning is considered the current practice to help offset the effects of immobility Keeping the head of bed at is an intervention to help prevent VAP What Are the Average Costs of Immobility for Organizations? 17

18 ICU Statistics In the United States: >6,000 ICU beds 1 >5 million patients admitted annually to the ICUs 1 ICU patients represent 10% of admissions but 30% of hospital costs 2 Average mortality in ICUs is 10%-29% 1 Average LOS in the ICU is days 1 1. Society of Critical Care Medicine. Critical care statistics in the United States. Mount Pleasant, IL: Society of Critical Care Medicine; Accessed 7/27/ Pendergraft TB, et al. Ann Allergy Asthma Immunol. 2004;93: Rhodes A, et al. Intensive Care Med. 2012;38: Vincent J, et al. Crit Care Med. 2006;34: Edbrooke DL, et al. Crit Care. 2011;15:R56. Unplanned ICU Readmissions Respiratory complications are the major reason 1 Reintubation is associated with increased risk of developing VAP 2,3 Development of an HAI is associated with readmission of 27days 6 Average ICU readmission rate of 7% and average ICU daily costs of $3,184 1,4 ICU readmissions have twice the average hospital LOS 1 Hospital death rates are times higher 1 1. Rosenberg AL, Watts C. Chest. 2000;118: Torres A, et al. Am J Respir Crit Care Med. 1995;152: Elward AM, et al. Pediatrics. 2002;109: Dasta JF, et al. Crit Care Med. 2005;33(6): Emerson CB, et al. Infect Control Hosp Epiemiol, 2012:33:

19 Functional Status at Discharge: Impact on Readmission Single center retrospective cohort study of 9405 consecutive patients admitted from an acute care hospital to an inpatient rehab Functional status on admission to rehab was assessed (FIM score) and categorized into low, middle and high functional status Results 13% readmission rate Low and middle FIM score was significantly associated with readmission in comparison to high FIM scores across diagnostic categories Medical patients with the lowest functional status had the highest readmission rate The Centers for Medicare and Medicaid Services will reduce payments to hospitals with excess readmissions (admissions within 30 days of discharge) 2 FIM= functional independent measure 1.Hoyer EH, et. al. Journal of Hospital medicine. 2014;9: Readmissions reduction program. CMS website. Accessed. Impact of Pressure Ulcers In the United States: Acute care facility-acquired pressure ulcer rate: 0-12% 1 60,000 deaths from facility-acquired pressure ulcer complications per year 2 Average cost of facility-acquired stage III or IV pressure ulcers: $43,180 3 $11 billion per year in preventable costs 4 1. National pressure ulcer Advisory panel, European pressure ulcer Advisory panel and Pan Pacific pressure injury alliance. Clinical practice guideline, Courtney BA, et al. Nurs Manage. 2006;37:36,38, CMS Office of Public Affairs. Fact sheet: CMS proposes additions to list of hospital-acquired conditions for fiscal year Baltimore, MD: Centers for Medicare & Medicaid Services; 4/14/ Reddy M, et al. JAMA. 2006;296: Phillips L, Buttery J. Nurs Times. 2009;105: Bennett G, et al. Age Ageing. 2004;33:

20 Quality Implications Centers for Medicare & Medicaid Services (CMS) Increasing number of quality measures 1 CMS financial pressures for quality reporting 2,3 Excessive readmission penalties begin in CMS Value-Based Purchasing 5 CMS-based program Started in October 2012 Pay-for-performance CMS will withhold in % of payments and redistribute the money based on how well hospitals meet quality measures compared to baseline measures The Joint Commission 6 National patient safety goals for 2015: Patient identification Infection prevention Medication safety Effective communication Surgical mistakes Patient safety risks clinical quality measures tipsheet. Tipsheet.pdf. 2. FY2009 quality measure reporting for 2010 payment update. HospitalQualityInits/Downloads/HospitalRHQDAPU pdf. 3. CMS quality measurement programs characteristics. downloads/cmsqualitymeasurementprogramscharacteristics.pdf. 4. Readmissions reduction program Hospital value-based purchasing program. CMS website. Hospital_VBPurchasing_Fact_Sheet_ICN pdf Patient Safety Goals Summary: Institutional Costs Associated With Immobility ICU patients represent a disproportionate amount of hospital costs Respiratory complications are the major reason for unplanned ICU readmissions ICU readmissions average longer hospital LOS and higher mortality rates Facility-acquired pressure ulcers represent a large preventable cost There may be long-term financial implications associated with poor performance with regard to healthcare safety indicators through the CMS Value-Based Purchasing Program 20

21 It is not enough to do your best; you must know what to do, and THEN do your best. W. Edwards Deming Introduction to Early Mobility 21

22 Definition of Early Mobility 1 Early mobility definition: Planned movement in a sequential manner beginning at a patient s current mobility status and returning the patient to baseline Early mobility includes: Head elevation Manual turning Passive and active range of motion Continuous lateral rotation therapy/prone positioning Movement against gravity Physiologic adaptation to an upright/leg down position (Tilt Table, bed egress) Chair position Dangling Ambulation 1. Vollman KM. Crit Care Nurse. 2010;30:S3-S5. What Does Clinical Evidence Tell Us About Early Mobility? 22

23 Start at the Top: Which Head of Bed Is at 30? Garcia R. Presented at: APIC The Clinical Impact of 45 Head of Bed on Ventilator-Associated Pneumonia (VAP) 1 Number of patients 86 Patient population Intervention Results Monitored clinically suspected and microbiologically confirmed nosocomial pneumonias Randomly assigned to: Supine position (n=47) Head of bed 45 (n=39) Microbiologically confirmed nosocomial pneumonia lower in the semirecumbent group, 2/39 (5%) vs 11/47 (23%) Supine position and enteral nutrition were independent risk factors for VAP and had the greatest number of VAP cases 14/28 (50%) 1. Drakulovic MB, et al. Lancet. 1999;354:

24 A Comparison of Two Measurements of Head of Bed on VAP 1 Number of patients 221 Patient population Critically ill patients undergoing mechanical ventilation Intervention Results Randomly assigned to Head of bed 10 (n=109) Head of bed 45 (n=112) Head of bed elevation was measured continuously Backrest elevation was measured continuously Average elevation range in the first week - 10 group: group: (intended elevation was not achieved 85% of the time) Microbiologically confirmed VAP occurred in 7.3% of patients in the 10 group and in 11.6% of the 45 group VAP=ventilator-associated pneumonia. 1. Van Nieuwenhoven CA, et al. Crit Care Med. 2006;34: The Clinical Impact of Manual Turning on VAP 1 Study Evaluate frequency of bihourly turning (16 hours 3 days) 284 ICU patients, tube fed and on mechanical ventilation Results 49% of patients developed VAP Patients with VAP were turned less frequently Mean number of turns was 9.64/patient vs 23 possible bihourly turns VAP=ventilator-associated pneumonia. 1. Schallom L, et al. Am J Crit Care. 2005;14:

25 Continuous Lateral Rotation Therapy CLRT mechanism of action A gentle side-to-side, full-body motion of the patient in which one lung is placed above the other This motion allows for gravitational flow and mobilization of pulmonary secretions, as well as enhance gas exchange What impact does it have on gas exchange? Increased oxygen Decreased CO 2 Improved blood flow Decreased atelectasis What happens inside the airways when patients are turned? Table-Based vs Cushion-Based Rotation Turning on the long axis Measured in degrees of angle/turn 124 (62 per side) in 3.5 minutes Unstable spine patients Rotates patient by inflation/deflation of air cushions Longitudinal, full-body rotation Measured in percent of air bladder inflation 25

26 Key Differences Table-Based Rotation Ideally suited for patients with unstable heads, necks, and spines (neuro and trauma patients) 1 Uses a firm mattress essential for maintenance of spine alignment 1 Can potentially put skin integrity at risk Can be set by degree of angle desired Requires 2 fixed planes to accurately determine angle Table-based products can achieve this as both the surface and the frame are moving at the same angle Cushion-Based Rotation Usually does not require transfer to a different surface, allowing it to be initiated more readily More user-friendly for clinicians 1 Beds may include additional features such as assist modes for patient positioning 1 1. Basham KA, et al. Respir Care Clin N Am. 1997;3: Cross Section of a Chest in the Supine Position Lung Sternum Heart Rib Bronchi Pulmonary Infiltrates Spine 26

27 Rotation of the Chest Supine Position Pulmonary infiltrates are unable to drain into the bronchi Rotation of the Chest Pulmonary infiltrates are unable to drain into the bronchi 27

28 Rotation of the Chest Pulmonary infiltrates are unable to drain into the bronchi Rotation of the Chest Some amount of drainage of pulmonary infiltrates into the bronchi 28

29 Rotation of the Chest Pulmonary infiltrates can successfully drain into the bronchi 180 Systematic Review and Meta-Analysis of Rotational Bed Therapy to Prevent and Treat Respiratory Complications 1 Methods: Systematic review and meta-analysis of studies on prophylaxis and/or treatment Prospective, randomized controlled trials Various types of beds were studied Table- and cushion-based therapies Kinetic (62 ) and CLRT (40, 30, and 20 ) CLRT=continuous lateral rotation therapy. Goldhill DR, et al. Am J Crit Care. 2007;16:

30 Review and Meta-Analysis of Rotational Bed Therapy to Prevent and Treat Respiratory Complications: Meta-Analysis of Pneumonia 1 Rotational therapy provides a benefit with respect to the incidence of pneumonia Goldhill DR, et al. Am J Crit Care. 2007;16: Review and Meta-Analysis of Rotational Bed Therapy to Prevent and Treat Respiratory Complications 1 Conclusions: Little evidence on which rotation parameter is most effective Effectiveness may not depend entirely on the angle of rotation, but also on Frequency and duration of rotation Pause time Underlying disease Size and weight of patient Use of adjuncts such as vibration, percussion, or pulsation Some awake patients do not tolerate steep angle rotation May be best for patients with higher BMI, unconscious, or sedated Key recommendation: Rotational therapy may be useful for preventing and treating respiratory complications in selected critically ill patients receiving mechanical ventilation Goldhill DR, et al. Am J Crit Care. 2007;16:

31 Rotational Therapy Using Cushion-Based Rotation The Medical Center of Central Georgia evaluated the impact of CLRT A CLRT protocol was implemented in patients who were identified as at risk for pulmonary complications, and outcomes were compared with a historical comparison group Vent Days ICU Days When introduced early, CLRT may reduce critical care length of stay and cost to treat CLRT is an option for patient mobility Hospital Days Cost to Treat, Thousands of Dollars ICU Readmission Rates, % Reintubation Rates, % No CLRT CLRT after 48 hours CLRT within 48 hours CLRT=continuous lateral rotation therapy. No CLRT: 75 patients; CLRT after 48 hours: 46 patients; CLRT within 48 hours: 50 patients. Swadener-Culpepper L, et al. Crit Care Nurs Q. 2008;31: CLRT to Prevent VAP: Controlling the Variables 1 Methodology Prospective randomized controlled trial, 3 medical ICUs at a single center Eligible if ventilated <48 hours and free from pneumonia, ALI, or in ARDS 150 patients with 75 in each group 35 patients with CLRT allocated to undergo percussion before suctioning Measures to prevent VAP were standardized for both groups including head of bed Results: CLRT vs control VAP: 11% vs 23% P=0.048 Ventilation duration: 8 ± 5 days vs 14 ± 23 days, P=0.02 LOS: 25 ± 22 vs 39 ± 45 days, P=0.01 Mortality: no difference ALI=acute lung injury; ARDS=acute respiratory distress syndrome; CLRT=continuous lateral rotation therapy; VAP=ventilator-associated pneumonia. Staudinger T, et al. Crit Care Med. 2010;38:

32 Introducing CLRT Into Patient Care Introduction of CLRT into patient care can provide an efficient way of providing early mobility to those critically ill patients whose condition or instability prevents implementation of other forms of mobility 1,2 Systematic method of approaching placement and removal of CLRT therapy a protocol CLRT=continuous lateral rotation therapy. 1. Swadener-Culpepper L, et al. Crit Care Nurs Q. 2008;31: Basham KA, et al. Respir Care Clin N Am. 1997;3: Moving Those Who Cannot Move Themselves: Which Patients Should Receive CLRT? Target high-risk patient populations Pulmonary-hemodynamic instability with manual turning FiO 2 50% or more Positive end-expiratory pressure (PEEP) 8 or more Existing pulmonary complications FiO 2 increases by 20% (20 points) or PEEP >3 cm H 2 O from baseline within 2 calendar days Which patients should NOT receive CLRT? Those with unstable spines Those with long bone fractures or patients requiring traction Those with unstable intracranial pressure Marked agitation without therapeutic management Those with severe, uncontrolled diarrhea and patients that weigh more than 300lbs CLRT=continuous lateral rotation therapy. Swadener-Culpepper L, et al. Crit Care Nurs Q. 2008;31: Basham KA, et al. Respir Care Clin N Am. 1997;3:

33 Ongoing Monitoring/Evaluation and Documentation Assess for potential complications frequently Malposition of endotracheal tube Positional transient desaturation Positional hemodynamic instability Every 2 hours check to see if patient is in optimal position to promote effective turn Every 2 hours manually turn patient and evaluate skin and lungs, then resume rotational therapy Document in medical record: degree of rotation, pause time settings, hours of rotation, turn for skin check and lung evaluation every 2 hours Discontinue CLRT when the patient: May be mobilized safely using other means (head of bed, chair position, out-of-bed chair, and/or ambulation) Shows improvement in respiratory status Has agitation that is not therapeutically managed CLRT=continuous lateral rotation therapy. CLRT Strategies for Success Early CLRT intervention The therapy must be driven by a protocol and changes in settings are nursing orders Monitor initial rotation cycle to ensure one lung is above the other Automation of rotation requires insertion of usual assessment practices Minimum of 18 hours per day and 6 cycles per hour If done incorrectly, can cause skin injury Shorter pause times Assessment to ensure one lung above the other Every two-hour assessment of the lungs and skin Yearly competency-based education to ensure proper use of the therapy CLRT=continuous lateral rotation therapy. 33

34 Prone Positioning: 2013 Evidence RCT 466 patients with severe ARDS (26 ICU s in France/1 Spain) Severe ARDS P/F ratio < 150 mm Hg, with Fio2 0.6, PEEP of at least 5 cm of water, & a V t of 6 ml per kg of PBW Initiation 12-24hrs Prone-positioning 16hrs/or supine position/ (proned within 1hr of randomization) NMB used 5 days Stopping prone treatment After 4hrs in supine meeting oxygenation criteria in PaO2/FiO2 ratio of 20% (after 2 consecutive prone positions) Complications leading to immediate interruption Applied for 28 days, then clinician discretion Guerin C. et al. N Engl J Med, 2013, 368(23): Results: Guerin C, et. al. Prone Study Results: Baseline characteristics similar except for, vasopressors (S), sepsis related SOFA score (S) & use of NMB s (P) Prone 16% mortality, supine 32.8% p< Prone group ICU LOS (2 days, & VFD (4 days) (NS) No differences in complications except > cardiac arrest in supine position (31 S vs. 16 P) Guerin C. et al. N Engl J Med, 2013, 368(23):

35 Evidence for Active and Passive Range of Motion 1-3 When muscles are immobilized in shortened positions, there is remodeling of muscle fibers Bed rest entails immobilization of limb extensor muscles in shortened positions Passive movement has been shown to enhance ventilation, prevent contractures in patients in high-dependency units Low-resistance multiple repetition muscle training can augment muscle mass and strength Sets of repetitions to perform daily within patient tolerance recommended by ICU patient. e.g. 3 sets of 8-10 repetitions at 50-70% of 1 rep max. 1. Gosselink R, et al. Intensive Care Med. 2008;34: Perme C, Chandrashekar R. Am J Crit Care. 2009;18: Schweickert WD, et al. Lancet. 2009;373: The Clinical Outcomes of an Early Mobility Protocol: Methods Prospective cohort study to determine the impact of early mobility therapy on mechanically ventilated with respiratory failure The control group received standard passive ROM and turning (n=165) The study group received low-impact mobility (n=165) Assessment & therapy initiated within 48 hours of mechanical ventilation by a team Therapy 7 days/week until ICU discharge Mobility team included 1 ICU nurse, 1 physical therapist, and 2 nursing assistants ROM=range of motion. Morris PE, et al. Crit Care Med. 2008;36:

36 The Clinical Outcomes of an Early Mobility Protocol: Results The early mobility protocol: Shortened time to patient first out of bed ( =6.3 days) Hospital LOS ( =3.3 days) ICU LOS ( =1.4 days) PT session during hospital stay Cost per patient including team Intervention Group Control 80% 47.7% $41,142 $44,302 LOS=length of stay. Morris PE, et al. Crit Care Med. 2008;36: Early Physical and Occupational Therapy of Mechanically Ventilated Patients Impact Outcomes 104 adults fully functional at baseline, sedated and on mechanical ventilation (for less than 72 hours) in the ICU Patients : Intervention group: planned daily activity during interruption of sedation (n=49) Control group: daily interruption of sedation with standard care (n=55) Patients assigned to the early mobilization had: Fewer hospital days with delirium (28% as compared to 41% in the control group) More ventilator-free days (23.5 as compared to 21.1 in the control group) A higher probability of returning to independent functional status at hospital discharge (59% of patients as compared to 35% in the control group) Shorter Time from Intubation to PT/OT=physical/occupational therapy; ROM=range of motion. Schweickert WD, et al. Lancet. 2009;373: Intervention (days) Control (days) First PT/OT session Out of bed Standing Transfer to chair Walking

37 Summary: Clinical Evidence for Early Patient Mobility Manual turning, head of bed, continuous lateral rotation therapy, passive and active range of motion, as well as sitting in the chair and ambulating are part of early patient mobility Early activity is feasible and safe in patients with respiratory failure Overcoming Barriers to Early Mobility 37

38 Potential Barriers to Early Mobilization Patients noted to be turned less often 1 : Heavier patients * Patients receiving vasopressors * Patients receiving a paralytic agent at least once Trauma patients with multiple fractures or high intracranial pressure Perceived patient and environmental barriers to mobilizing ICU patients 2,4 : Fear of line dislodgement Heavy sedation Patient comfort Human and technological resources Weaning patients served as their own control. Out of Bed chair vs : No difference in ABG s, respiratory or hemodynamic values 3 Fear of further decreases in oxygenation or hemodynamic parameters 1. Schallom L, et al. Am J Crit Care. 2005;14: Morris PE. Crit Care Clin. 2007;23: Thomas P, et al. Heart & Lung. 2014;43: Jolley SE, et al. BMC Anesthesiology,. 2014;14:1-9 * *not statistically significant Feasibility and Safety of Early Activity in Patients With Acute Respiratory Failure: Methods 103 patients who are mechanically ventilated for >4 days Mobility team included registered nurse, physical therapist, respiratory therapist, and care technician Patients assessed upon admission and daily for readiness Activity begins when patient exhibits physiologic stability Sedation reduced and oxygen levels supported Measures of activity related adverse events Fall to knees, systolic blood pressure >200 or <90 mm Hg, oxygen desaturation <80% and/or extubation, and/or tube removal Bailey P, et al. Crit Care Med. 2007;35:

39 Feasibility and Safety of Early Activity in Patients With Acute Respiratory Failure: Results Measured 1,449 activity events Sit on bed (16%), sit in chair (31%), and ambulate (53%) Patients with an endotracheal tube in place had 593 activity events 249 (42%) were ambulated 69% survivors ambulated >100 feet at respiratory ICU discharge <1% activity-related adverse events Photo courtesy of Bailey P, et al. Crit Care Med. 2007;35: Bailey P, et al. Crit Care Med. 2007;35: Feasibility and Safety of Early Activity in Mechanically Ventilated Patients Methods: Study included 49 ICU patients who had been mechanically ventilated for <72 hours 43% of the patients had ARDS on ICU admission Patients received daily sedative interruption and were screened for the safety of PT/OT PT/OT progressed from passive/active range of motion through bed mobility exercises followed by sitting at the edge of the bed, balance activities, ADLs, transfers, and finally ambulation Results: Average time from intubation to initial therapy was 1.5 days Therapy occurred on 87% of total eligible days on study 90% of days on mechanical ventilation 90% of days in the ICU while not on mechanical ventilation Patients had ICU delirium during 53% of sessions Adverse events only occurred during 16% of all PT/OT sessions, including desaturation 5%, heart rate increase, ventilator asynchrony/tachypnea, agitation/discomfort, and device removal ARDS=acute respiratory distress syndrome; PT/OT=physical/occupational therapy. Pohlman MC, et al. Crit Care Med. 2010;38:

40 Yes. They Can Be Mobilized Published literature on safe use of early mobilization with various patient populations Continuous renal replacement therapy 1,2 Extracorporeal membrane oxygenation 3,4 Burns 5 Abdominal surgery 6 1. Wang YT, et al. Critical Care. 2014;18:R Talley, et al. Critical Care Nursing Quarterly (1): Abrams D, et al. Critical Care. 2014;18:R38 4. Freeman R, et al. Critical Care Nursing Quarterly (1): Taylor S, et al. Critical Care Nursing Quarterly (1): Havey R, et al. Critical Care Nursing Quarterly (1):63-72 The Role of Hemodynamic Instability in Positioning 1,2 Lateral turn results in a 3%-9% decrease in SVO 2, which takes 5-10 minutes to return to baseline Appears the act of turning has the greatest impact on any instability seen Minimize factors that contribute to imbalances in oxygen supply and demand Factors that put patients at risk for intolerance to positioning: 3 Elderly Diabetes with neuropathy Prolonged bed rest Low hemoglobin and cardiovascular reserve Prolonged gravitational equilibrium 1. Winslow EH, et al. Heart Lung. 1990;19: Price P. Dynamics. 2006;17: Vollman KM. Crit Care Nurs Q. 2013;36:

41 Decision-Making Tree for Patients Who Are Hemodynamically Unstable With Movement 1,2 Screen for mobility readiness within 8 hrs of admission to ICU & daily initiate in-bed mobility strategies as soon as possible Is the patient hemodynamically unstable with manual turning? O 2 saturation < 90% New onset cardiac arrhythmias or ischemia HR < 60 <120 MAP < 55 >140 SPB < 90 >180 New or increasing vasopressor infusion Yes Is the patient still hemodynamically unstable after allowing 5-10 minutes adaption post-position change before determining tolerance? Yes Screen for mobility readiness within 8 hrs of admission to ICU & daily initiate inbed mobility strategies as soon as possible Yes Has the manual position turn or HOB elevation been performed slowly? Yes Initiate continuous lateral rotation therapy via a protocol to train the patient to tolerate turning No No No No Begin in-bed mobility techniques and progress out-of-bed mobility as the patient tolerates Begin in-bed mobility techniques and progress out-of-bed mobility as the patient tolerates Allow the patient a minimum of 10 minutes of rest between activities, then try again to determine tolerance Try the position turn or HOB maneuver slowly to allow adaption of cardiovascular response to the inner ear position change HOB=head of bed; HR=heart rate; MAP=mean arterial pressure; SPB=systolic blood pressure. Vollman KM. Crit Care Nurse. 2012;32: Vollman KM. Crit Care Nurs Q. 2013;36: Mobility Initiative to Overcome Process/ Culture Barriers: Methods Multicenter implementation of key mobility related clinical interventions Development of an evidence-based, user-friendly early mobility continuum Implementation plan: process design, culture work, and education 130 patients/3,120 prospectively collected hourly observations Qualitative and quantitative data collected Results Qualitative reports suggest that the collaborative approach improved both the culture and team focus on the process of mobility A reduction in ventilator days (3.0 days pre vs 2.1 days post) approached significance (P=0.06) Figure used with the permission of Rick D. Bassett. Bassett RD, et al. Intensive Crit Care Nurs. 2012;28:

42 Cultural Adaptation to Increase Sustainability Vollman KM, Bassett R. Transforming the Culture: The Key to Hardwiring Early Mobility & Safe Patient Handling. Amer Nurse Today, 2014, September Average ICU Costs Potential Cost Savings if 1 Day Reduced ICU LOS (with no mechanical ventilation) in an ICU With an Average of 500 Patients Annually ICU reduced LOS 1 day ICU cost/day $3,184 ICU savings/patient $3,184 Annual number of ICU patients 500 Annual ICU LOS savings $1,592,000 Potential Cost Savings if 1 Day Reduced ICU LOS (with mechanical ventilation) in an ICU With an Average of 200 Vent Patients Annually Reduced ventilator days 1 day Vent cost/day $3,968 Vent savings/patient $3,968 Annual number of vent patients* 200 Annual ventilator savings $793,600 Early mobility has the potential to help reduce ICU LOS for non-vented and vented patients, creating the potential for significant savings. 1. Dasta JF, et al. Crit Care Med. 2005;33(6):

43 Financial Model for Cost Effectiveness Lord R. Crit Care Med, 2013;41:717 Care Bundles and Protocols 43

44 ABCDE Bundle to Mitigate ICU-Acquired Delirium and Weakness ABCDE bundle = Awakening and Breathing Coordination, Delirium monitoring, and Exercise/early mobility ABCDE is designed to: Promote collaboration among clinical team members Standardize care Break the ICU ventilation-sedation-delirium-weakness cycle National resources materials available to help implement: ICU liberation SCCM collaborative at AACN CSI Academy & Clinical toolkit: Implementing ABCDE at Vasilevskis EE, et al. Chest. 2010;138: ABCDE Bundle Clinical Evidence The ABCDE bundle was evaluated in critically ill patients receiving mechanical ventilation in a prospective before-after study of 186 patients from 5 ICUs (93 patients pre-abcde bundle implementation and 94 patients post implementation) After ABCDE bundle implementation, patients experienced more days breathing without assistance (average of 24 days without vent assistance vs 21 days in the pre-bundle group) and were less likely to experience ICU delirium (66% vs 75.3% in the pre-bundle group) A prospective study evaluated nonventilated patients in the ICU both prior to (n=53) and after (n=56) the implementation of the ABCDE bundle ABCDE bundle implementation resulted in a reduction in the overall incidence (19.6% vs 39.6% in the pre-bundle group) and duration of delirium in nonventilated ICU patients 1. Balas M, et al. Crit Care Med May;42(5):

45 (Appendix A) NeuroIntensive Care Unit Progressive Upright Mobility Protocol (PUMP) Plus Algorithm START HERE Assess patient (pt.) for the following: Pt. at risk for/has deconditioning due to immobility? OR Does pt. require orthostatic training to upright position? N N Use of a of a Mobility Bundle Toolkit and Technology in a Neurointensive Care Unit Is the pt. immobile or have ineffective mobility plus one or more of: Lobar collapse, atelectasis, excessive secretions? P/F Ratio < 300? Hemodynamic instability with manual turning ( O 2Sat; BP, HR)? Pt. able to ambulate at all? Y Y N Initiate or continue PUMP Steps Proceed to PUMP PLUS Steps 6 through 11 Y Notify primary MD to prescribe appropriate activity orders for pt. Initiate/continue Cont. Lateral Rotation Therapy (CLRT) Titsworth WL. J Neurosurg, : N Y CONTRAINDICATIONS? Include but are not limited to unstable spine, active stroke alerts and/or up to 24hours after receiving tpa or endovascular intervention, increased intracranial HTN, active resuscitation for life-threatening hemodynamic instability, femoral sheaths, traction, CRRT, aggressive modes of ventilation and palliative care. Assess skin q2hours. Temporarily offload Pressure areas for circulatory recovery. Do not use turning wedges during rotation. Q shift: assess pt. progress towards expected outcomes; adherence to rotation goals; tolerance to therapy; clinical contraindications (listed above) Does the pt. meet CLRT discontinuation criteria: CXR improved/resolving infiltrates; P/F ratio> 300; stable hemodynamically; improved secretion mgmt; pt. turns self? PUMP STEPS: Progress each step from minutes. Each step must be implemented at least three times/day and more frequently as tolerated. Repeat each step until patient demonstrates clinical tolerance to stated activity/position, then advance to next step, at the next activity period opportunity. * It is highly recommended to coordinate pt. mealtime with mobility steps whenever possible. STEP 1: HOB elevated at 45 STEP 2: HOB elevated at 45 plus legs in dependent position (partial chair mode or cardiac chair) STEP 3: HOB elevated at 45 plus legs in full dependent position (full bed chair mode/cardiac chair) STEP 4: HOB elevated at 65 plus legs in full dependent position & feet on floor & standing in place *If cardiopulmonary intolerance develops, use reverse T-Berg for orthostatic training TID, until resolved. STEP 5: Initiate stand position/pivot and into chair STEP 6: (PLUS) Transfer standing from bed to chair for 2-3 meals with sitting time not to exceed 45min. STEP 7 (PLUS): Ambulate within room using assistive devices & extra personnel PRN (goal = 20 feet) STEP 8 (PLUS): Ambulate within hallway using assistive devices & extra personnel PRN (goal = 50 feet) STEP 9 (PLUS): Ambulate within hallway using assistive devices & extra personnel PRN (goal = 100 feet) STEP 10 (PLUS): Ambulates 150 ft with contact guard (hands on only for balance) or personnel supervision/assistance (coaching only). STEP 11: (PLUS): Ambulates without coaching or supervision, may use device if necessary. Y N All patient admitted over 16 month period 10 month pre-obs- 6 month post 100% Nurse-driven protocol One protocol for nurses to follow; all patients Mobility goals for patients with or without deconditioning Defined steps beyond chair to better prepare patients for discharge, earlier End point mobility goals similar to outpatient PT goals Modified from The University of Kansas Hospital Progressive Mobility Algorithm for Critically Ill Patients ( Shands at the University of Florida, 2010 Courtesy of J Hester. Use of a of a Mobility Bundle Toolkit and Technology in a Neurointensive Care Unit (NICU) Mobility was increased among the NICU care patients by 300% Titsworth WL. J Neurosurg, :

46 Protocol Driven Mobility Program: Impacting NICU Outcomes Pre-post intervention study Large academic NICU 637 patients 260 pre 377 post Intervention: Early Progressive Mobility Protocol Exclusion criteria Readiness criteria Started on admission Encourage to use ICU bed features & lifts to assist Protocol place at bedside Klein K, et al. Crit care Med, 2015, epub Protocol Driven Mobility Program: Impacting NICU Outcomes Multivariate analysis done to control for group differences: K, et al. Crit care Med, 2015, epub 46

47 Where Do We Stand One day point prevalence study on early mobilization of mechanically ventilated patients 116 ICUs in Germany (2011) 783 patients data Results 24% mobilized out of the bed Endotracheal tube (8%) Tracheostomy, (39%) Noninvasive ventilation(53%) Common barriers Cardiovascular instability (17%) Deep sedation (15%) Out of bed mobilization was not associated with a higher frequency of complications Nydahl P, et al. Crit Care Med, 2014;42(5): International Survey of Early Mobilization Practices: Where Do We Stand Surveyed directors of medical and mixed medical surgical ICUs in 4 countries Institutions selected a random Results 833 ICUs (US 396; France 151, UK 138, Germany 148) 27% reported having a formal EM protocol 21% have adopted him practices without a protocol 52% have not adopted EM practices EM protocols applied to both ventilated and non-ventilated upon ICU admission Factors associated with EM protocol presence of multidisciplinary rounds (US) written daily goals (US) Sedation protocol (US) Bakhru RN, et al. Amer J of Respir & Critical Care Medicine. 2014;A

48 How Can We Implement a Program to Help Patients Achieve Early Mobility and Potentially Reduce Organizational Costs? Utilizing bed systems combined with lifts and a early mobility protocol, caregivers can progress patients from the flat/supine position through exiting the bed safely, easily, and more often. This early mobility protocol is a simplified process of small, interventional activities that can be easily accomplished at the bed side with a minimum number of caregivers. 48

49 Initial Patient Assessment Assess patients mobility levels within 8 hours of admission to the ICU and reassess at least every 24 hours Mobility Level Criteria Start at Level 1 if: PaO 2 /FiO 2 <250 Positive end-expiratory pressure (PEEP) 10 cm H 2 O O 2 saturation <90% Respiratory rate (RR) Not within per min. Cardiac arrhythmias or ischemia New onset Heart rate (HR) <60 or >120 beats per min. Mean arterial pressure (MAP) <55 or >140 mm Hg Systolic blood pressure (SBP) <90 or >180 mm Hg Vasopressor infusion New or increasing Richmond agitation sedation scale (RASS) < 3 Riker sedation-agitation scale (SAS) <3 Adapted from Bassett RD, et al. Intensive Crit Care Nurs. 2012;28: Early Mobility Protocol Level 1: Breathe Patient Assessment Breathe RASS 5 to 3; SAS 1-2 (eg, cannot participate) HOB angle improve VAP protocol compliance The Centers for Disease Control and Prevention recommends an HOB angle of 30-45, unless contraindicated 1 Visually confirm the HOB is elevated 30 to comply with VAP prevention protocols Activities Every-2-hour turning Passive range of motion 20 Reverse Trendelenburg/Tilt Table with lower extremity exercises/retracting footboard 1. Tablan OC, et al. MMWR Recomm Rep. 2004;53:

50 Early Mobility Protocol Level 1: Breathe (Cont.) Breathe Continuous lateral rotation therapy (CLRT) can be considered part of early mobility therapy in patients who are at high risk for pulmonary complications 1 CLRT provides side-to-side rotation to help facilitate gravitational effects on pulmonary secretions and blood flow Consult the CLRT Quick Reference Guide for additional information The CLRT QRG provides information regarding patient assessments and activities to be implemented in both hemodynamically stable and hemodynamically unstable patients 1. Swadener-Culpepper L, et al. Crit Care Nurs Q. 2008;31: Where Does CLRT Fit Into a Early Mobility Program? CLRT=continuous lateral rotation therapy; PEEP=positive end-expiratory pressure. 50

51 Where Does CLRT Fit Into a Early Mobility Program? (Cont.) Activities Activities Activities Activities CLRT=continuous lateral rotation therapy; PEEP=positive end-expiratory pressure. CLRT Quick Reference Guide CLRT Protocol for Hemodynamically Stable Patients CLRT=continuous lateral rotation therapy. * This tool is provided for education and discussion only. Each facility is responsibility for the development, adoption and implementation of its own protocols. Follow protocols and rules adopted by your facility. 51

52 CLRT Quick Reference Guide CLRT Protocol for Hemodynamically Unstable Patients CLRT=continuous lateral rotation therapy. * This tool is provided for education and discussion only. Each facility is responsibility for the development, adoption and implementation of its own protocols. Follow protocols and rules adopted by your facility. Early Mobility Program Protocol Level 1: Breathe (Cont.) Breathe Move to Level 2 when the patient Has acceptable oxygenation/hemodynamics Tolerates every-2-hour turning Tolerates HOB>30 or Reverse Trendelenburg 20 52

53 Early Mobility Program Protocol Level 2: Tilt Patient Assessment Tilt RASS > 3; SAS >3 (eg, opens eyes; may have profound weakness) 20 Reverse Trendelenburg/Tilt Table position Tilt Table positioning allows for orthostatic training in fragile patients 1 If available, use in conjunction with retracting foot section to allow for partial weight bearing prior to sitting up in bed or getting out of bed Activities Maintain head of bed 30 Every-2-hour turning Passive/active range of motion Legs dependent (partial chair) PT consultation 1. Trees D, Coale N. Acute Care Perspect. 2007;16:6-9. Early Mobility Protocol Level 2: Tilt (Cont.) Tilt Move to Level 3 when the patient Tolerates active-assistance exercises 2 times a day Tolerates lower extremity exercises against footboard/20 Reverse Trendelenburg Tolerates partial chair position (legs dependent/hob 30 ) Can move arms against gravity 53

54 Early Mobility Protocol Level 3: Sit Patient Assessment RASS > 1; SAS >3 (eg, weak but may move arms/legs independently) Sit Chair mode (footboard on) Full upright positioning allows for diaphragmatic excursion and lung expansion Sitting with legs in a dependent position facilitates gas exchange Activities Maintain head of bed 30 Every-2-hour turning (assisted) Active range of motion Encourage activities of daily living Dangling PT/Occupational therapist actively involved Early Mobility Protocol Level 3: Sit (Cont.) Sit Move to Level 4 when the patient Tolerates increasing active exercise in bed Actively assists with every-2-hour turning or turns independently Tolerates chair position 3 times/day Can move leg against gravity 54

55 Early Mobility Protocol Level 4: Stand Patient Assessment RASS >0; SAS >4 (eg, weak but may tolerate increased activity) Stand Stand Attempts Chair egress position (footboard off/feet on the floor) Consider using a sit-to-stand lift If tolerates partial weight bearing, pivot to chair Activities Maintain head of bed 30 Every-2-hour turning (self/assisted) Active range of motion Encourage activities of daily living PT/OT actively involved Early Mobility Protocol Level 4: Stand (Cont.) Stand Move to Level 5 when the patient Can successfully comply with all activities Tolerates trial periods of chair egress position (footboard off/feet on the floor) 3 times a day Tolerates partial weight-bearing stand and pivots to chair 55

56 Early Mobility Protocol Level 5: Move Patient Assessment RASS >0; SAS >4 (eg, weak but may tolerate increased activity) Move Achieve out-of-bed orders Utilize mobile floor lift (or ceiling lift) to ambulate to bedside chair Activities Maintain head of bed 30 Every-2-hour turning (self/assisted) Active range of motion Encourage activities of daily living Patient stands/bears weight >1 minute Patient marches in place PT/ OT actively involved Patients continue to ambulate progressively longer distances as tolerated until they consistently participate and move independently Summary: Implementing the Early Mobility Protocol Using Technology Implementation of the early mobility protocol may result in better clinical outcomes and financial outcomes Clinical outcomes may include patients getting off the ventilator sooner, less VAP, less potential for skin injury, and a reduction in delirium Financial outcomes may include decreased ICU LOS, decreased ventilator days, and decreased hospital LOS Use of early mobility is safe It can be used in patients with ARDS or delirium It can increase the comfort of staff and patients Various tools and techniques can facilitate the implementation of a simple, 5-step early mobility protocol ARDS=acute respiratory distress syndrome; LOS=length of stay; VAP=ventilator-associated pneumonia. 56